COVID Antigen Test – Patient Registration Form

Cov-2 Patient Intake and Assessment Form

History of Present Illness

Do you have any symptoms of COVID-19?
Have you had a known exposure to COVID-19?
By signing below, I consent to receive the CareStart COVID-19 Antigen Rapid POC Test. I also recognize that, pursuant to South Carolina Law §44-29-10 and Regulation §61-20, my results will be reported to the SC Department of Health and Environmental Services, whether positive or negative.

For Pharmacy Use Only